than 50 percent of all adverse events

occurred within the first four days after

the TIA. Notably, of the patients with TIA
who returned to the emergency depart-
ment with stroke (10.5 percent), approxi-
mately one half had the stroke within
the first 48 hours after the initial TIA. In
2.6 percent of patients with TIA, hospi-
talization was required for cardiac events,
including congestive heart failure, unsta-
ble angina, cardiac arrest, and ventricular
arrhythmia.
Clinical Presentation
The more common clinical presenta-
tions of TIA are described in Table 1. In
general, a TIA presents as a syndrome
rather than any one sign or symptom.
Pre-emergency Department Care
There is no reliable way to determine
if the abrupt onset of neurologic deficits
represents reversible ischemia without
subsequent brain damage or if ischemia
will result in permanent damage to the
brain (e.g., stroke). Therefore, all patients
B
ased on an increased under-
standing of brain ischemia
and the introduction of new
treatment options, a working
group has proposed rede-
fining transient ischemic attack (TIA) as
a brief episode of neurological dysfunc-
tion caused by focal brain or retinal isch-
emia, with clinical symptoms typically
lasting less than one hour, and without
evidence of acute infarction.
1(p1715)
This
definition underscores the urgency of rec-
ognizing TIA as an important warning of
impending stroke and facilitating rapid
evaluation and treatment of TIA to pre-
vent permanent brain ischemia.
Epidemiology
An estimated 200,000 to 500,000 TIAs
occur annually in the United States.
2

One study
2
found that 25 percent of
patients who presented to an emergency
department with TIA had adverse events
within 90 days; 10 percent of the events
were strokes, and the vast majority of
the strokes were fatal or disabling.
3
More
Transient ischemic attack is no longer considered a benign event but, rather, a critical
harbinger of impending stroke. Failure to quickly recognize and evaluate this warning
sign could mean missing an opportunity to prevent permanent disability or death. The
90-day risk of stroke after a transient ischemic attack has been estimated to be approxi-
mately 10 percent, with one half of strokes occurring within the first two days of the
attack. The 90-day stroke risk is even higher when a transient ischemic attack results
from internal carotid artery stenosis. Most patients reporting symptoms of transient
ischemic attack should be sent to an emergency department. Patients who arrive at
the emergency department within 180 minutes of symptom onset should undergo an
expedited history and physical examination, as well as selected laboratory tests, to
determine if they are candidates for thrombolytic therapy. Initial testing should include
complete blood count with platelet count, prothrombin time, International Normalized
Ratio, partial thromboplastin time, and electrolyte and glucose levels. Computed tomo-
graphic scanning of the head should be performed immediately to ensure that there
is no evidence of brain hemorrhage or mass. A transient ischemic attack can be mis-
diagnosed as migraine, seizure, peripheral neuropathy, or anxiety. (Am Fam Physician
2004;69:1665-74,1679-80. Copyright 2004 American Academy of Family Physicians.)
Transient Ischemic Attacks:
Part I. Diagnosis and Evaluation
NINA J. SOLENSKI, M.D., University of Virginia Health Sciences Center, Charlottesville, Virginia
O A patient infor-
mation handout on
strokes and TIAs, writ-
ten by the author of
this article, is provided
on page 1679.
See page 1591 for defi-
nitions of strength-of-
recommendation labels.
COVER ARTICLE
This article
exemplifies the
AAFP 2004 Annual
Clinical Focus on caring
for Americas aging
population.
This is part I of a two-
part article on transient
ischemic attacks. Part
II, Treatment, will
appear in this issue on
page 1681.
Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright 2004 American Academy of Family Physicians. For the private, noncommercial
use of one individual user of the Web site. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
with symptoms of TIA should receive an
expedited evaluation.
Office staff should be trained to inform
the family physician immediately if a patient
calls or presents with symptoms that could
represent a TIA. Neurologic symptoms that
crescendo with increasing frequency, dura-
tion, or severity are particularly ominous signs
of impending stroke.
Most patients with possible TIA should be
sent immediately to the nearest emergency
department. If they have had symptoms
for fewer than 180 minutes, they should be
sent to an emergency department that offers
acute thrombolytic therapy. Patients should
not drive themselves to the hospital. To
speed evaluation, it is appropriate to activate
the 9-1-1 Emergency Medical Service system
for transport.
2,3
On presentation to the emergency depart-
ment, patients who have had symptoms for
fewer than 180 minutes might be candidates
1666-AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 7 / APRIL 1, 2004
The proposed redefinition of transient ischemic attack is a
brief episode of neurological dysfunction caused by focal
brain or retinal ischemia, with clinical symptoms typically
lasting less than one hour, and without evidence of acute
TABLE 1
Common Clinical Presentations of TIA
Affected area Signs and symptoms Implications
Cranial nerves Visual loss in one or both eyes Bilateral loss may indicate more ominous onset of brainstem
ischemia.
Double vision If double vision is subtle, the patient may describe it as
blurry vision.
Vestibular dysfunction True vertigo is likely to be described as a spinning sensation
rather than nonspecific lightheadedness.
Difficulty swallowing Trouble swallowing may indicate brainstem involvement; if the
swallowing problem is severe, there may be an increased risk
of aspiration.
Motor function Unilateral or bilateral weakness affecting Bilateral signs may indicate more ominous onset of brainstem
the face, arm, or leg ischemia.
Sensory function Unilateral or bilateral: either decreased If sensory dysfunction occurs without other signs or symptoms,
sensation (numbness) or increased the prognosis may be more benign, but recurrence is high.
sensation (tingling, pain) in the face,
arm, leg, or trunk
Speech and Slurring of words or reduced verbal output; If speech is severely slurred or facial drooling is excessive, there
language difficulty pronouncing, comprehending, is an increased risk of aspiration.
or finding words Writing and reading also may be impaired.
Coordination Clumsy arms, legs, or trunk; loss of balance Incoordination of limbs, trunk, or gait may indicate cerebellar
or falling (particularly to one side) with or brainstem ischemia.
standing or walking
Psychiatric or Apathy or inappropriate behavior These symptoms can indicate frontal lobe involvement and
cognitive frequently are misinterpreted as poor volitional cooperation.
function
Excessive somnolence This symptom may indicate bilateral hemispheric or brainstem
involvement.
Agitation or psychosis Rarely, these symptoms may indicate brainstem ischemia,
particularly if they occur in association with cranial nerve
or motor dysfunction.
Confusion or memory changes These rarely are isolated symptoms; more frequently, they are
associated with language, motor, sensory, or visual changes.
Inattention to surrounding environment, Depending on the severity of neglect, the physician may
particularly to one side; if severe, patient need to lift the patients arm to check for strength,
may deny deficit or even his or her own rather than rely on the patient to perform this task.
body parts.
TIA = transient ischemic attack.
for treatment with tissue-type plasminogen
activator (tPA).
4,5
If a patient is not a candi-
date for tPA treatment, antiplatelet therapy
should be initiated as soon as it can be deter-
mined that there are no contraindications.
4-6

[Reference 6: SOR A, rating of benefits]
Inpatient or Outpatient Evaluation
Guidelines issued by the National Stroke
Association
7
recommend evaluation within
hours of the onset of TIA symptoms, prefer-
ably in an emergency department. If appro-
priate imaging studies are not immediately
available in the emergency department or out-
patient setting, the patient should be hospital-
ized for observation.
7
[SOR C, expert opin-
ion] Relative indications for more extended
inpatient evaluation for TIA or stroke are
listed in Table 2.
Patients with symptoms of acute TIA for
fewer than 24 to 48 hours should undergo
diagnostic testing in the emergency depart-
ment.
8
[SOR C, expert opinion] Patients
whose symptoms have resolved for more than
48 hours should receive urgent inpatient or
outpatient evaluation.
Initial Work-Up for Suspected TIA
The first step in evaluating a patient with
symptoms of TIA is to confirm the diagnosis
(Figure 1).
DIFFERENTIAL DIAGNOSIS
The most common imitators of TIA are
glucose derangement, migraine, seizure, post-
ictal states, and tumors (especially with acute
hemorrhage).
TIA typically has a rapid onset, and maxi-
mal intensity usually is reached within min-
utes. Fleeting episodes lasting one or two sec-
onds or nonspecific symptoms such as fatigue,
lightheadedness (in the absence of other cer-
ebellar or brainstem symptoms), and bilateral
rhythmic shaking of the limbs are less likely
presentations of acute cerebral ischemia.
Distinguishing TIA from migraine aura
can be difficult. Younger age, previous his-
tory of migraine (with or without aura), and
associated headache, nausea, or photophobia
are more suggestive of migraine than TIA. In
general, migraine aura tends to have a march-
ing quality; for example, symptoms such as
tingling may progress from the fingers to
the forearm to the face. Migraine aura also is
APRIL 1, 2004 / VOLUME 69, NUMBER 7 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN-1667
Neurologic symptoms that crescendo with increasing fre-
quency, duration, or severity are particularly ominous signs of
impending stroke.
TABLE 2
Relative Indications for Inpatient Evaluation of Possible TIA or Stroke*
Condition Implications
High-risk cardioembolic source: acute myocardial infarction Consider anticoagulation.
(especially if large and significant wall-motion abnormality
is present), mural thrombi, new-onset atrial fibrillation
TIAs manifested by major symptoms such as dense paralysis Possible evolving large hemispheric stroke with increased risk of
or severe language disorder brain swelling
Increasing frequency or severity of TIAs (crescendo pattern) Possible evolving thromboembolic stroke
Evidence of high-grade carotid artery stenosis Carotid artery evaluation for possible emergency intervention (surgery,
stent, or angioplasty)
Drooling, imbalance, decreased alertness, difficulty Increased risk of falling, or of aspiration and other pulmonary
swallowing complications
Severe headache, photophobia, stiff neck, recent syncope Possible subarachnoid hemorrhage: obtain emergency computed
tomographic scan of the head; if the scan is negative but clinical
suspicion remains high, cerebrospinal fluid evaluation or possible
cerebral angiography is needed.
TIA = transient ischemic attack.
*May require more than 23 hours of observation in the emergency department, or hospitalization for observation.
more likely to have a more gradual onset and
resolution, with a longer duration of symp-
toms than in a typical TIA.
If a patient has explosive onset of a severe
headache, with or without photophobia, stiff
neck, or syncope, acute subarachnoid hemor-
rhage is a possibility. Rarely, TIA is mistaken
for the first presentation of multiple sclerosis
in young patients or for amyotrophic lateral
sclerosis in older patients.
HISTORY
A general medical history should be
obtained in all patients with suspected TIA.
Special emphasis should be given to pos-
sible symptoms of TIA (Table 1), and stroke
risk factors should be identified to determine
the likelihood that the symptoms are caused
by TIA. Modifiable risk factors for stroke
include hypertension, diabetes, cardiac dis-
ease, elevated blood lipid levels, carotid artery
stenosis, smoking, sickle cell anemia, excessive
alcohol use, obesity, and physical inactivity.
7
Whether hypercholesterolemia is an inde-
pendent primary risk factor for stroke remains
uncertain.
9
However, hypercholesterolemia is
a significant risk factor for coronary heart dis-
ease (CHD) and therefore can be considered
1668-AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 7 / APRIL 1, 2004
Initial Work-Up for Suspected TIA
FIGURE 1. Initial work-up for the patient with possible transient ischemic attack (TIA). (IV =
intravenous; tPA = tissue-type plasminogen activator; CT = computed tomography; ECG = elec-
trocardiography; PT = prothrombin time; aPTT = activated partial thromboplastin time; INR =
International Normalized Ratio; MRI = magnetic resonance imaging; MRA = magnetic resonance
angiography)
Frequent vital signs, with attention to blood pressure* and heart rhythm
Head CT*
Cardiac monitoring: ECG
Medical and neurologic examination*
Initial laboratory tests: complete blood count with platelet count*; electrolyte,
glucose,* and renal function measurements; PT,* aPTT,* and INR*
Carotid artery evaluation
Head MRI and MRA of intracranial and neck vessels, if available and appropriate
Further testing in selected patients (see Table 3)
Is patient a candidate for
thrombolytic therapy?
Initiate aspirin therapy
within 24 to 48 hours
(if no contraindications).
Perform certain tests (*) within 25 minutes of
patients arrival in emergency department; screen
for inclusion/exclusion criteria for IV tPA therapy.
Send patient to hospital emergency
department for evaluation.
Urgent outpatient evaluation to identify
cause of TIA; if imaging studies are not
available in a timely fashion, admit patient.
Identify and treat stroke risk factors.
Begin medical therapy, including antiplatelet
therapy, as soon as possible.
Acute (did transient symptoms occur <24 to 48 hours ago)?
Confirm TIA history.
Yes No
No Yes
an important risk factor for ischemic stroke.
There appears to be a stronger data relationship
between total and low-density lipoprotein cho-
lesterol levels, as well as a protective influence
of high-density lipoprotein cholesterol levels, in
cervical carotid artery atherosclerosis.
10
Other important information includes a
family history of stroke (including cerebral
aneurysm or hypercoagulable state), the use
of over-the-counter or illicit drugs, a history
of migraine or severe headaches, recent
head trauma, previous systemic clots and,
in a woman of childbearing age, a history of
spontaneous abortion. Certain findings may
indicate the need for special diagnostic tests
(Table 3).
PHYSICAL EXAMINATION
Vital signs should be evaluated, includ-
ing blood pressures in both arms, to rule
out stenosis of the subclavian artery, which
may manifest as grossly asymmetric pressures.
Auscultation of the heart and neck also should
be performed. Carotid bruits, when present,
are neither highly specific nor highly sensitive
for carotid artery stenosis.
All patients with possible TIA should
receive a detailed, documented neurologic
examination, with emphasis on cognitive and
language function, cranial nerve function,
facial and limb strength, sensory function,
deep tendon reflex symmetry, and coordi-
nation. This examination can be helpful in
determining whether a patient previously had
an unrecognized stroke. It also can serve as a
baseline examination if the patients neuro-
logic status worsens or neurologic symptoms
recur. Occasionally, the neurologic examina-
tion may identify a nonischemic cause for
an acute neurologic deficit (e.g., acute radial
nerve palsy, isolated third-nerve palsy in a
patient with diabetes mellitus).
DIAGNOSTIC TESTS
Brain Imaging. Computed tomographic
(CT) scanning of the head without contrast
medium should be performed to identify
subarachnoid hemorrhage, intracranial hem-
orrhage, or subdural hematoma. Urgent iden-
tification of these conditions is critical because
neurosurgical intervention or special manage-
ment may be required.
If hemorrhage is present, treatment with tPA
or anticoagulants that may worsen central ner-
vous system bleeding should be avoided. Spe-
cial measures may be needed to manage blood
pressure if the patient is found to have hyper-
tension-mediated intracranial hematoma, and
further testing may be required if the patient is
found to have subarachnoid hemorrhage (e.g.,
cerebral angiography to rule out aneurysm).
CT scanning also can identify conditions
that mimic TIA, including tumors and other
masses (especially if hemorrhage occurs
acutely within a mass), as well as conditions
that are associated with seizures or auras.
A head CT scan can identify signs of early
brain damage or evidence of old strokes.
11,12

Finally, CT scanning of the head with contrast
medium should be performed in the febrile
patient to rule out an infectious cause or in the
patient with a suspected mass (e.g., metastatic
carcinoma, abscess).
Because of increased bony artifact in the
posterior fossa, CT scanning is not sensitive
for evaluating disease in the brainstem or
cerebellum. In these instances, magnetic reso-
nance imaging (MRI) is the preferred study.
Electrophysiologic Testing. All patients should
have a baseline electrocardiogram (ECG) with
rhythm strip.
6,12,13
If the ECG is abnormal or the
patient has a history of cardiac disease, echocar-
diography should be performed. Atrial fibrilla-
tion and left ventricular hypertrophy (suggest-
ing unrecognized chronic hypertension) are
important risk factors for stroke. Recent data
suggest that the 90-day risk for a cardiac event
TIA
APRIL 1, 2004 / VOLUME 69, NUMBER 7 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN-1669
Conditions that may mimic TIA include glucose derangement,
migraine, seizure, postictal states, tumors or, rarely, multiple
sclerosis and amyotrophic lateral sclerosis.
is seven times higher in patients with TIA and
abnormal ECG findings than in those with a
normal ECG (4.2 versus 0.6 percent).
13
If the ECG is unrevealing, cardiac moni-
toring in selected patients could help diag-
nose paroxysmal atrial fibrillation (or other
arrhythmias in patients with syncope or pal-
pitations). In patients with untreated atrial
fibrillation, echocardiography may identify
a thromboembolic source or left ventricular
systolic dysfunction, both of which are com-
mon predictors of ischemic stroke.
14
Transesophageal echocardiography is super-
ior to transthoracic echocardiography for eval-
uating possible dysfunction of the left atrium
(including thrombus) or a patent foramen
ovale (an etiology for paradoxical emboli),
atrial septal defects (including aneurysm), and
aortic plaque. Recent clinical trials
15,16
suggest
that transesophageal echocardiography should
be considered in patients without an identifi-
able cause of TIA or known cardiac disease,
because it may detect a condition requiring
therapeutic intervention (e.g., anticoagulation
for thrombus). Aortic plaque, which has been
associated with stroke, can be visualized well on
transesophageal echocardiography.
Laboratory Tests. A complete blood count
with platelet count should be obtained to rule
out polycythemia, thrombocytopenia, and
thrombocytosis. It is helpful to know the pro-
thrombin time (PT), activated partial throm-
boplastin time (aPTT), and International
Normalized Ratio (INR) before antiplatelet or
anticoagulation therapy is administered; the
PT, aPTT, and INR can be elevated in some
hypercoagulable states.
The glucose level should be determined to
1670-AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 7 / APRIL 1, 2004
TABLE 3
Further Diagnostic Testing Based on the History in Patients Undergoing Evaluation for Possible TIA*
History Implications Tests
Headache in postpartum Venous thrombosis MRI with venography or cerebral angiography
or dehydration setting
Fever Subacute or acute bacterial Blood cultures, head CT scan with and without contrast medium;
endocarditis in selected patients with confirmed bacterial endocarditis,
perform cerebral angiography to rule out a mycotic aneurysm.
Confusion, headache, CNS vasculitis Cerebral angiography, ESR, lumbar puncture (to look for elevation of
seizure white blood cell counts in particular)
Hypertensive encephalopathy Careful blood pressure monitoring in intensive care setting; consider
MRI.
Rheumatologic disease, CNS vasculitis Consider cerebral angiography, ESR, lumbar puncture (to look for
sympathomimetic drug use elevation of white blood cell counts in particular).
Recent myocardial infarction Cardioembolic source Transthoracic or esophageal echocardiography
Head, neck, jaw pain, Carotid or vertebral dissection Consider cerebral angiography or other neck neuroimaging studies
especially after trauma (see text).
Abrupt onset of severe Subarachnoid hemorrhage Emergency head CT scan; if the scan is negative, evaluate
headache with cerebrospinal fluid for elevated red blood cell count or perform
photophobia, or cerebral angiography to rule out aneurysm or arteriovenous
recent syncope malformation.
Confusion, stupor, coma, Vertebrobasilar ischemia Consider intracranial magnetic resonance angiography or cerebral
other brainstem symptoms angiography; if basilar artery is significantly thrombosed, consider
(poor prognosis) intra-arterial thrombolytic therapy (if available).
Brain swelling, impending Immediate head CT scan; if the scan is positive, emergency
herniation neurosurgical intervention may be required.
No obvious risk factors Cryptogenic stroke, patent Consider cerebral angiography, transesophageal echocardiography,
for stroke foramen ovale, intra-atrial and work-up for hypercoagulable state.
septal aneurysm, valvular
or aortic arch disease
TIA = transient ischemic attack; MRI = magnetic resonance imaging; CT = computed tomography; CNS = central nervous system;
ESR = erythrocyte sedimentation rate.
*The initial work-up for the patient with possible TIA is outlined in Figure 1.
rule out hypoglycemia or hyperglycemia and to
help diagnose occult diabetes. Blood urea nitro-
gen and creatinine levels are important, because
poor renal status may prohibit the use of con-
trast media in imaging studies. An erythrocyte
sedimentation rate (ESR) should be obtained to
potentially rule out vasculitis. Finally, a drug of
abuse screen, a pregnancy test, a homocystine
level determination, or a blood alcohol level
measurement should be performed in selected
patients.
Follow-Up Evaluation
LIPID PROFILE
After the initial more abbreviated evalua-
tion in the emergency department, risk factors
for stroke can be reassessed thoroughly later
in the evaluation. Recent data indicate that
treatment with statins (3-hydroxy-3-methyl-
glutaryl coenzyme A reductase inhibitors)
reduces the risk of stroke by about 30 percent
in patients with CHD.
17,18
Therefore, a fasting
lipid profile reflective of the patients normal
eating habits should be obtained, and statin
therapy should be initiated if indicated.
HYPERCOAGULABLE STATES
Patients with known risk factors for stroke
and those with a history of migraine, sponta-
neous abortion, pulmonary emboli, or deep
venous thrombosis, or a family history of any
of these conditions, should be evaluated for
hypercoagulable states. Initial tests include
ESR, antinuclear antibody test, rapid plasma
reagent test, and antiphospholipid antibody
tests. Referral to a hematologist or neurolo-
gist can ensure cost-effective evaluation of
the multiple coagulation-factor abnormalities
and conditions that can cause embolic stroke.
TESTING FOR ARTERIAL PATENCY
AND BLOOD FLOW
Carotid duplex ultrasonography should be
performed in a reliable laboratory, preferably
one with validation against the results of cere-
bral angiography. Alternatively, cerebral and
cervical vessels can be evaluated by magnetic
resonance angiography (MRA) with contrast
medium or by CT angiography. If the work-
up demonstrates carotid or other large-vessel
atherosclerotic disease in the patient with TIA
and unrecognized CHD, coronary artery test-
ing is recommended.
19
MRI. Clear advantages of MRI of the brain
over CT scanning of the head include better
imaging of tissues (i.e., greater sensitivity for
early edema), superior imaging within the
posterior fossa (including the brainstem and
cerebellum), additional planes of imaging
(sagittal, coronal, and oblique), and no expo-
sure to radiation.
A clear disadvantage of brain MRI is that it
may or may not identify hemorrhage. For this
reason, although MRI can be helpful, it should
not replace urgent CT scanning of the head in
the initial work-up of patients with possible
TIA. When cerebrovascular malformation,
aneurysm, cerebral venous thrombosis, or arte-
ritis is suspected, MRI or MRA is preferred.
Diffusion-weighted imaging detects cellular
edema as early as 10 to 15 minutes after symp-
tom onset. However, this technique is not yet
widely available.
MRA. This imaging modality is a noninva-
sive means of assessing intra- and extracranial
vessels. Current MRA techniques use intrave-
nously administered contrast medium (gado-
linium) to visualize the vessels.
MRA with the administration of con-
trast medium also is effective in identify-
ing vertebrobasilar stenosis, although recent
data suggest that intracranial vertebral artery
disease can be missed.
20
Depending on the
MRA acquisition technique, the percent-
age of intracranial vessel stenosis can be
overestimated (sensitivity of approximately
85 percent compared with cerebral angiog-
raphy).
21
Therefore, if accuracy is therapeu-
tically important, cerebral angiography is
necessary.
When near occlusion of the carotid artery
cannot be distinguished from complete occlu-
sion on MRA or carotid Doppler ultrasound
studies, cerebral angiography should be con-
TIA
APRIL 1, 2004 / VOLUME 69, NUMBER 7 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN-1671
sidered. Surgery generally cannot be per-
formed on completely occluded vessels.
Special consideration should be given to
patients who present with a history or symp-
toms that suggest arterial dissection. This con-
dition can be diagnosed using neck MRI scans
in certain sequences that can identify hemor-
rhage within the vessel wall (T
1
-weighted
images with fat suppression).
Patients with carotid artery dissection can
present with acute or subacute unilateral
neck, head, or jaw pain. These symptoms may
be associated with visual or language deficits,
or with sensorimotor deficits, particularly in
the opposite arm. More typically, patients
with carotid artery dissection present with
only some of these features, such as temporal
headache with lateral neck pain and, possi-
bly, transient visual obscuration (amaurosis
fugax) because of thromboemboli in the oph-
thalmic artery.
Both carotid and vertebral artery dis-
sections have been described after trauma,
although spontaneous dissection also is com-
mon. Patients should be evaluated for con-
nective tissue disease because of the associated
increased risk of dissection.
If the MRI or MRA study is inconclusive,
cerebral angiography should be used to rule
out arterial dissection or better define the
percentage of vessel narrowing.
CT Angiography. This modality is another
state-of-the-art technique for detecting
blood flow to the brain. CT angiography also
is becoming a useful imaging modality for
identifying carotid or vertebral artery dissec-
tion. Because the technique requires venous
injection of contrast dye, the patients renal
status should be considered before the test is
performed.
Conventional CT scanning in combination
with CT angiography currently is being evalu-
ated as an addition to the diagnostic imaging
tools for use in patients with TIA or stroke.
This combination can provide useful infor-
mation about vascular anatomy (in the form
of three-dimensional reconstructions) and
the extent and location of infarction. It may
allow rapid evaluation of patients with TIA or
stroke in hospitals or institutions that do not
have MRI capability.
Cerebral Angiography. This technique con-
tinues to be the gold standard for complete
evaluation of intracranial and extracranial ves-
sels. With cerebral angiography, both arterial
and venous phases of cerebral blood flow can
be visualized (dynamic study). However, cere-
bral angiography is an invasive technique that
can result in neurologic complications (total
incidence rate: 1.3 to 4.6 percent),
22,23
includ-
ing major stroke or death in 0.1 to 1.3 percent
of patients, depending on the study.
24,25
Relative indications for cerebral angiog-
raphy include suspected carotid dissection
unconfirmed on a noninvasive neuroimaging
study, subarachnoid hemorrhage (to identify
bleeding source), intracerebral hemorrhage in
the absence of hypertension, and vasculitis. If
one of these conditions is suspected, referral
to a neurologist can be helpful in obtaining
and interpreting the angiogram.
Special Considerations
VERTEBROBASILAR ISCHEMIA
Typical signs and symptoms of ischemic
syndromes involving the anterior and pos-
terior circulations are listed in Table 4. The
brainstem and cerebellum are confined within
the posterior fossa, a bony cavity with poor
tolerance of brain swelling or mass effects
(e.g., from hemorrhage). Because brainstem
structures are essential for preserving criti-
cal respiratory function and arousal states,
1672-AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 7 / APRIL 1, 2004
The Author
NINA J. SOLENSKI, M.D., is associate professor of neurology and a staff member of the
Stroke Center at the University of Virginia Health Sciences Center, Charlottesville. Dr.
Solenski received her medical degree from Jefferson Medical College of Thomas Jeffer-
son University, Philadelphia, and completed a neurology residency and cerebrovascular
fellowship at the University of Virginia Health Sciences Center.
Address correspondence to Nina J. Solenski, M.D., Stroke Center, Department of
Neurology, P.O. Box 800394, University of Virginia Health Sciences Center, Hospital
Dr., McKim Hall, Room 2055, Charlottesville, VA 22908 (e-mail: njs2j@virginia.edu).
Reprints are not available from the author.
patients with vertebrobasilar ischemia should
be monitored closely. It also is crucial to search
for life-threatening cerebrovascular disease,
such as basilar artery stenosis or thrombosis
or disease affecting multiple large vessels (e.g.,
bilateral, vertebral, or carotid artery stenosis).
TIA IN A YOUNG PATIENT
When a TIA occurs in a patient younger
than 45 years, particularly if there are no clear
risk factors for stroke, it is advisable to refer
the patient to a neurologist for consideration
of specialized testing. For example, it may be
necessary to determine the utility of cerebral
angiography to rule out vasculitis, carotid
artery dissection, and other forms of nonath-
erosclerotic vasculopathy, or lumbar spinal
puncture with cerebrospinal fluid evaluation
may be required to rule out chronic infection
or inflammation.
Because cardiac abnormalities are among
the most common causes of TIA in young
patients, a baseline ECG with rhythm strip
should be obtained, and transthoracic and
transesophageal echocardiography should be
considered. A toxicology screen for drugs
of abuse (especially sympathomimetic com-
pounds) usually is performed.
Several newly identified, genetically based
metabolic and hematologic syndromes have
been found to be associated with stroke. With
some of these syndromes, initial symptoms
occur in the younger years (late childhood,
adolescence, or early adulthood). Diagnosis
of these syndromes may require specialized
tests. Such testing could be important to bet-
ter define treatment options and prognosis, as
well as to identify family members who may
APRIL 1, 2004 / VOLUME 69, NUMBER 7 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN-1673
TABLE 4
Typical Characteristics of Ischemic Syndromes Involving the Anterior and Posterior Circulations
Ischemic syndrome:
circulation involved Signs Symptoms
Anterior circulation* Visual-field cut Inability to see well (i.e., difficulty reading or driving
Language dysfunction (left hemisphere most Difficulty finding or understanding words, inability to read,
often affected): aphasia garbled or slurred speech
Motor dysfunction: contralateral face, arm, Dropping objects; depending on severity, inability to lift
or leg weakness or move a body part or objects
Sensory dysfunction: contralateral increased Tingling (paresthesias), numbness, or pain
or decreased sensation to pain, heat, or cold
Behavior dysfunction (right hemisphere): The patient usually reports no symptoms, but family
inattention to surrounding environment, members or others report that the patient has difficulty
particularly to one side; if severe, patient dressing, ignores half of food on a plate, or has poor
may deny deficits or even his or her own attention to one side of the room or to someone speaking
body parts to the patient on one side versus the other (most often,
the left side is ignored).
Posterior circulation Nystagmus Vertigo (spinning sensation)
Disconjugate gaze If subtle, blurry or double vision
Homonymous visual-field cut Inability to see well, especially to one side
Contralateral weakness Dropping objects, inability to fully lift or move the limb
Incoordination of trunk or limbs (ataxia) Clumsiness, falling, inability to coordinate an action
(e.g., drink from a cup without spilling contents)
Motor or sensory dysfunction on opposite For example, the patient may report double vision,
side of cranial nerve deficits (crossed signs droopiness on the left side of the face, and dragging
suggest brainstem involvement) of the right leg (because of weakness).
Bilateral signs Abrupt weakness of both legs, falling
Decreased mentation; stupor or coma Family members or others report that the patient has poor
responsiveness or that they are unable to arouse the patient.
*Includes the internal carotid artery, middle cerebral artery, and anterior cerebral artery, as well as the branches of these arteries.
Includes the vertebral arteries, basilar artery, and posterior cerebral artery, as well as the branches of these arteries.
TIA
be at risk for TIA or stroke.
The author indicates that she does not have any con-
flicts of interest. Sources of funding: none reported.
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1674-AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 69, NUMBER 7 / APRIL 1, 2004